Specialty Pharmacy Insights

Regardless of income or political affiliation, we all agree that Americans deserve the dignity of a secure retirement after paying into Medicare and Social Security throughout their working lives. We can also agree that seniors managing an acute or chronic disease deserve access to critical medications. But the efforts made to protect our seniors’ healthcare is under attack from unfair fees that jeopardize specialty pharmacies and the patients they serve.

Just as primary care doctors refer patients to specialists to treat more complex diseases, a specialty pharmacy manages care for the most vulnerable patients. Their medications are often complex, high-cost prescriptions that require customized patient care. Direct and Indirect Remuneration or "DIR" fees are penalties issued by pharmacy benefit managers (or PBMs). These DIR fees are meant to create accountability for traditional pharmacies filling traditional prescriptions, but they have dramatic unintended consequences for specialty pharmacies and their patients.

It’s important to remember that only a small number of Americans require complex specialty drugs and specialty support. Yet big PBMs are holding specialty pharmacies to standards that were not designed to deal with the unique services and needs of specialty patients. At the same time, specialty pharmacies are trying to provide a high level of service that a traditional pharmacy just doesn’t provide.

Here's an example to explain how DIR fees work:

Any time a Medicare D patient with diabetes misses a prescription refill, the traditional pharmacy that provides that prescription receives a penalty from the PBM. This could be a dollar amount or a percentage of the prescription cost. But if that patient filled their diabetes prescription at a specialty pharmacy, along with a more expensive prescription to cure hepatitis, the same penalty would be applied to both prescriptions, even though the measurement to assess the penalty would only apply to the diabetes prescription. Then, this same fee would be applied to other prescriptions for specialty medications, even when those prescriptions are not related to the original DIR fee. These fees force specialty pharmacies to reduce the very services that make them so special. Absent these independent specialty pharmacy services, the only remaining option for seniors would be to seek services from enormous pharmacies owned by the very same PBMs that impose the penalties.

To solve this, we need to make big PBMs replace existing DIR fees with a program based on applicable performance metrics. We need to replace existing DIR fees with a "fair play" model, so specialty pharmacies can continue to provide the quality care that our most vulnerable seniors deserve.

“DIR fees assessed by drug plans and their pharmacy benefit managers (PBMs) are taking away our ability to expand our population health initiatives and our ability to support important foundational healthcare things that we can do as a pharmacy,” says Don Carroll, Associate Chief of Pharmacy, Cleveland Clinic.

If you want to help protect patient care, visit StopDIRFees.com which serves as a resource to learn about DIR fees and their catastrophic impact to patient care. Resources include 3rd party videos, articles from leading media outlets, white papers, and positions from legislatures and industry experts. We encourage you to explore the resources, better understand the issue, and take action against DIR fees by staying informed and telling Congress to support legislation banning retroactive DIR fees.